00:01
Okay. Osteoarthritis is the most common kind of arthritis.
00:04
Let’s talk about treatment.
00:06
Once again, I’ve hit on the same theme.
00:08
Acetaminophen is generally less effective than NSAIDs moderately,
but it's a lot safer.
00:13
That’s why it’s usually considered first-line.
00:16
It's amazing that tramadol or opiates are
recommended or used for osteoarthritis because
even in clinical research
they really aren't very effective at all.
00:26
Sometimes not much more than placebo
and less so than NSAIDs.
00:30
So, therefore, they don't have a strong
role among patients with osteoarthritis.
00:35
But corticosteroid injections can help.
00:38
And this is the kind of ladder.
00:39
Start with acetaminophen and NSAIDs.
00:42
NSAIDs try to – I try to keep them – I’ll keep them high dose,
but limit for the most severe types of pain.
00:48
If that fails, I’ll actually send the patient
directly in for a corticosteroid injection.
00:54
Typically, it's going to be knees.
00:56
Sometimes, it’s going to be shoulder or hip.
00:59
But those injections are relatively safe.
01:01
There's very few systemic side effects.
01:04
And they can generally go for injections four times per year.
01:08
But say they're doing worse
and the injections didn’t work anymore,
if they’re getting only three or four weeks of improvement,
then they need another injection.
01:18
We can’t do that many injections.
01:20
We can’t do 12 injections per year obviously.
01:23
Unfortunately, that’s the time to think about surgery.
01:25
So, when other treatments fail
and the symptoms are limiting function,
so that's the other key criteria, I think, for joint replacement
would be not only is it painful, but it's painful
and it limits what I'm able to normally do,
think about surgery.
01:43
How about rheumatoid arthritis?
How do we go about managing that?
So, the treatment really is different and it’s that early initiation
of DMARDs (or disease-modifying anti-rheumatalogic drugs),
that's key.
01:56
We often start with methotrexate and hydroxychloroquine.
01:59
That's still effective.
02:00
Even though they are older agents,
those are effective for a lot of
patients with rheumatoid arthritis.
02:07
And with biologic therapies, there's a
lot of different options out there.
02:13
Certainly, you want to initiate them sooner rather than later.
02:16
You don't want to let them linger on just methotrexate or
hydroxychloroquine when they're progressing in terms of their disease,
but choosing between them can be very complicated.
02:25
Their side effects can be complicated and,
therefore, it's best left to the rheumatologist.
02:29
But don't forget, these patients
are still going to have acute flares.
02:33
There's evidence that both NSAIDs
and corticosteroids can be effective.
02:36
They work about equally well.
02:38
For most patients, the side effects of NSAIDs,
while prominent,
are less than that of corticosteroids.
02:44
So, try to stick to those.
02:47
How about gout?
We haven't talked about that as much.
02:50
So, gout starts with lifestyle,
avoiding foods and drinks associated with
higher rates of uric acid and more gout.
03:00
Allopurinol or febuxostat, they're both effective for
reducing the concentration of uric acid and,
subsequently, the risk of flares of gout.
03:12
Colchicine is a second line drug.
03:14
And during flares itself,
that’s not the time to initiate
uric acid reduction therapy.
03:20
Treat till the exacerbation terminates
with either NSAIDs or corticosteroids.
03:27
Again, they work about equally well.
03:29
So, for most patients, NSAIDs are a better choice.
03:32
So, that was a brief review of arthritis and,
hopefully, you got a sense of avoiding the
overuse of routine rheumatologic tests
where there's going to be a lot of false
positives that throw you off the track,
but do use x-rays early in cases of osteoarthritis.
03:51
We talked about the ladder of treatment for osteoarthritis
and the early initiation of DMARD
therapy for rheumatoid arthritis.
03:58
Thanks very much.